Injury to the Tarsometatarsal Joint Complex Michael C. Thompson, MD, and Matthew A. Mormino, MD Abstract Lisfranc described amputations through the tarsometatarsal (TMT) joint for the treatment of severe, gangrenous mid- foot injuries, and his name has been associated with many different inju- ries to this region. 1 Myerson 2 described such injuries as involving the tarsometa- tarsal complex (TMC), which includes the metatarsals and TMT joints, the cuneiforms, the cuboid, and the na- vicular. 2 The spectrum of TMC injury ranges from low-energy trauma, such as a misstep, to high-energy crush in- juries characterized by extensive os- seous comminution and soft-tissue com- promise. Accordingly, the pattern of TMC injury is highly variable and may involve purely ligamentous disrup- tions without fracture, associated meta- tarsal fractures, or fractures of the cu- neiforms, cuboid, or navicular. Accurate diagnosis of these inju- ries is paramount. Although only min- imal displacement may be present on initial radiographs, severe ligamen- tous disruption might still exist. Left untreated, such disruption may result in marked disability characterized by painful posttraumatic arthritis and pla- novalgus deformity. 3,4 A high index of suspicion should be maintained when examining a patient with an injured foot because delayed or missed diag- nosis occurs in up to 20% of cases. 5-7 The goal of treating TMC injury is to obtain a plantigrade, stable, pain- less foot. Successful outcome largely is related to obtaining and maintain- ing an anatomic reduction. 5,6,8,9 Ear- ly studies documented the failure of closed reduction to maintain an an- atomic reduction. 10-12 In 1982, Hard- castle et al 13 reported that open tech- niques with temporary, nonrigid fixation occasionally resulted in late displacement. Rigid screw fixation, the technique reported by Arntz et al 6 in 1988, has become the preferred meth- od for stabilization of these injuries. 5 Anatomy and Biomechanics Understanding the anatomy of the TMC is imperative for accurate assess- ment and treatment of injuries. Sta- bility of the complex is achieved by a combination of bony architecture and ligamentous support. The medial, mid- dle, and lateral cuneiforms articulate distally with the first, second, and third metatarsals, respectively 14 (Fig. 1, A). The cuboid articulates distally with the fourth and fifth metatarsals. The middle cuneiform is recessed proxi- mally relative to the medial and lat- eral cuneiforms. This mortise config- uration accommodates the base of the second metatarsal and lends additional osseous stability at this articulation. In the coronal plane, stability is fur- ther enhanced by the so-called Roman arch configuration of the metatarsal bases, with the second metatarsal base acting as the keystone (Fig. 1, B). Ligaments supporting the TMC are grouped according to anatomic lo- cation (dorsal, plantar, and in- terosseous). The lesser metatarsals are bound together by dorsal and plan- tar intermetatarsal ligaments (Fig. 1, A). Similarly, dorsal and plantar in- tertarsal ligaments hold the cunei- forms and cuboid together. There are Dr. Thompson is Chief Resident, Department of Orthopaedic Surgery and Rehabilitation,Creighton- Nebraska Health Foundation, University of Ne- braska Medical Center, Omaha, NE. Dr. Mormino is Assistant Professor and Director, Orthopaedic Trauma, Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center. Reprint requests: Dr. Mormino, 981080 Nebraska Medical Center, Omaha, NE 68198-1080. Copyright 2003 by the American Academy of Orthopaedic Surgeons. Tarsometatarsal joint complex fracture-dislocations may result from direct or in- direct trauma. Direct injuries are usually the result of a crush and may involve as- sociated compartment syndrome, significant soft-tissue injury, and open fracture- dislocation. Indirect injuries are often the result of an axial load to the plantarflexed foot. Midfoot pain after even a minor forefoot injury should raise suspicion; up to 20% of tarsometatarsal joint complex injuries are missed on initial examination. An anteroposterior radiograph with abduction stress may reveal subtle injury, but computed tomography is the preferred imaging modality. The goal of treatment is the restoration of a pain-free, functional foot. The preferred treatment is open re- duction and internal fixation, using screw fixation for the medial three rays and Kirschner wires for the fourth and fifth tarsometatarsal joints. Satisfactory outcome can be expected in approximately 90% of patients. J Am Acad Orthop Surg 2003;11:260-267 260 Journal of the American Academy of Orthopaedic Surgeons no ligamentous connections between the first and second metatarsal bases. The largest and strongest interos- seous ligament in the TMC is the so- called Lisfranc ligament, which aris- es from the lateral surface of the medial cuneiform and inserts onto the medial aspect of the second metatar- sal base near the plantar surface. 14 The first metatarsal base is anchored to the dorsal and plantar aspects of the me- dial cuneiform by two longitudinal ligaments. The peroneus longus and tibialis anterior tendon insertions fur- ther stabilize the first TMT joint. A variable network of longitudinal and oblique ligaments secures the remain- der of the metatarsals to the cunei- forms and cuboid on the dorsal and plantar aspects of the complex. In general, the dorsal ligaments are weaker than their plantar counter- parts. To a lesser extent, the plantar fascia and intrinsic musculature of the foot add stability to the TMC. Because of the unique bony and lig- amentous anatomy of the TMC, nor- mal motion of the individual compo- nents varies. Having articular contact with all three cuneiforms, the base of the second metatarsal demonstrates very little motion under normal cir- cumstances, with an average dorsi- flexion-plantarflexion arc of 0.6°. 15 In comparison, dorsiflexion-plantarflexion at the third TMT joint is approximately 1.6°, and, at the first joint, 3.5°. The fourth and fifth TMT joints are the most mobile, demonstrating an average of 9.6° and 10.2° of dorsiflexion- plantarflexion, respectively. 15 Injury to the Tarsometatarsal Joint Complex The overall annual incidence of TMC injuries is approximately 1 per 60,000 persons, 13,16 and the injury is two to three times more common in males (Table 1). Motor vehicle accidents are the most frequently cited mechanism, accounting for about 40% to 45% of injuries. Low-energy mechanisms ac- count for approximately 30%. Falls from a height and crush injuries are also commonly reported causes. The mechanism of TMC injury may be either direct or, more commonly, indirect trauma. The direct mechanism involves high-energy blunt trauma, usually applied to the dorsum of the foot. Crush injuries constitute most of these injuries, and many are associ- ated with notable soft-tissue trauma. Associated compartment syndromes and open fracture-dislocations are more often present with direct inju- ry mechanisms. In part as a result of Figure 1 A, Anteroposterior view of the bony and ligamentous anatomy of tarsometa- tarsal joint complex. I through V = metatar- sal bones. (Adapted with permission from Myerson MS: Fractures of the midfoot and forefoot, in Myerson MS: Foot and Ankle Dis- orders. Philadelphia, PA: WB Saunders, 2000, vol 2, pp 1265-1296.) B, Coronal section through the metatarsal bases illustrating the Roman arch configuration. (Adapted with permission from Lenczner EM, Waddell JP, Graham JD: Tarsal-metatarsal [Lisfranc] dis- location. J Trauma 1974;14:1012-1020.) Table 1 Tarsometatarsal Joint Complex: Mechanisms of Injury No. of Injuries (%) Study No. of Patients/ Injuries (M/F) Motor Vehicle Accident Fall From Height Crush Other Kuo et al 5 48/48 (32/16) 20 (42) 7 (14.5) 6 (12.5) 15 (31) Arntz et al 6 40/41 (28/12) 21 (51) 7 (17) 0 (0) 13 (32) Vuori et al 16 66/66 (46/20) 22 (33) 9 (14) 14 (21) 21 (32) Myerson et al 9 52/55 (NA) 34 (62) 8 (14.5) 8 (14.5) 5 (9) Hesp et al 36 23/23 (16/7) 19 (83) 3 (13) 1 (4) 0 (0) Hardcastle et al 13 119/119 (86/33) 48 (40.3) 16 (13.5) 0 (0) 55 (46.2) Wilppula et al 12 26/26 (21/5) 7 (27) 0 (0) 8 (31) 11 (42) NA = not available. Michael C. Thompson, MD, and Matthew A. Mormino, MD Vol 11, No 4, July/August 2003 261 the associated soft-tissue trauma and greater degree of articular injury, di- rect injuries often result in a worse clin- ical outcome compared with indirect injuries. 8,9 The indirect mechanism of injury usually involves axial loading of the plantarflexed foot. An example is a football player falling onto the heel of another player whose foot is planted and plantarflexed. This type of injury also can occur with soccer, basketball, and gymnastics. 17 Falls from a height may result in forefoot plantarflexion at the time of impact. In automobile accidents, injury to the plantarflexed foot occurs with a combination of de- celeration and floorboard intrusion. Less commonly, violent abduction or twisting of the forefoot may result in fracture-dislocation around the TMC. The fracture pattern and direction of dislocation in direct injuries are highly variable and depend on the force vector applied. In contrast, the most frequent pattern seen in indirect injuries involves failure of the weak- er dorsal TMT ligaments in tension, with subsequent dorsal or dorsolat- eral dislocation of the metatarsals. Mi- nor displacement at the TMT joint level results in a marked reduction in articular contact. Dorsolateral dis- placement of the second metatarsal base of 1 or 2 mm results in the re- duction of the TMT articular contact area by 13.1% and 25.3%, respective- ly. 18 Although fractures of the cune- iforms are relatively common, the most frequent fracture in TMC inju- ries involves the second metatarsal base. 16 Less common are associated fractures of the cuboid, navicular, or other metatarsals. Diagnosis The diagnosis of high-energy or crush injuries to the TMC is relatively straightforward. Examination typical- ly reveals moderate to severe swell- ing of the forefoot and, in open inju- ries, disruption of the skin and subcutaneous tissue. Inspection of the foot may reveal gross morphologic ab- normalities such as widening or flat- tening. A gap between the first and second toes is suggestive of intercu- neiform disruption as well as TMT joint injury. 19,20 Palpation of the dor- salis pedis artery may not be pos- sible, depending on the extent of swelling and deformity.Although dis- ruption of the dorsalis pedis artery has been reported, the incidence of vas- cular injury appears to be rare. 7,21,22 Significant pain on passive dorsiflex- ion of the toes in a tensely swollen foot is suggestive of a compartment syn- drome; however, evaluation may be hampered by pain associated with the osseous injury. 23,24 When there is un- certainty about the presence of a com- partment syndrome, pressures should be measured.An absolute pressure >40 mm Hg is diagnostic and an indica- tion for emergent compartment re- lease. Particularly in the hypotensive patient, a compartment pressure with- in 30 mm Hg of the diastolic pressure also is an indication for release. Findings after a low-energy TMC injury may be relatively subtle.Ahigh index of suspicion should be main- tained in the patient with forefoot pain after even a minor traumatic event. Patients usually have notable pain on weight bearing or are unable to bear weight on the affected foot. Swelling is present to a variable ex- tent, and ecchymosis occasionally is found along the plantar aspect of the midfoot. 25 Palpation of the affected TMT joints usually reveals tender- ness. Notable pain on passive abduc- tion and pronation of the forefoot also is suggestive of TMC injury. 17 The initial radiographic examina- tion should include anteroposterior, lateral, and 30° oblique views of the foot. To visualize the Lisfranc joint in the tangential plane, the anteropos- terior radiograph should be taken with the beam approximately 15° off vertical. Standing radiographs are ideal but may be difficult to obtain secondary to pain (Fig. 2, A and B). If weight-bearing views are not pos- sible, a stress view with the forefoot in abduction often will reveal subtle instability, especially at the first TMT joint. 17,26 All radiographs should be evaluated for signs of instability. On the anteroposterior view, the distance between the first and second metatar- sal bases varies among uninjured in- dividuals, with up to 3 mm consid- Figure 2 A, Anteroposterior non–weight-bearing radiograph of a patient with forefoot pain after an axial load injury. Note the subtle widening (arrow) between the bases of the first and second metatarsals. B, Anteroposterior standing view of the same patient as in Panel A dem- onstrating subluxation (arrow) at the base of the second metatarsal. C, Anteroposterior view of a patient with avulsion of the Lisfranc ligament, or fleck sign (arrow), at the base of the second metatarsal. Injury to the Tarsometatarsal Joint Complex 262 Journal of the American Academy of Orthopaedic Surgeons ered normal. 26,27 In subtle cases, radiographs of the contralateral foot should be obtained for comparison. Stein 28 reviewed 100 radiographs of normal feet and noted several con- stant anatomic relationships. On the anteroposterior view, the medial bor- der of the second metatarsal is in line with the medial border of the mid- dle cuneiform, the first metatarsal aligns with the medial and lateral bor- ders of the medial cuneiform, and the first and second intermetatarsal space is continuous with the intertarsal space of the medial and middle cuneiforms (Fig. 1, A). On the 30° oblique view, the medial border of the fourth meta- tarsal is in line with the medial bor- der of the cuboid, the lateral border of the third metatarsal is aligned with the lateral border of the lateral cune- iform, and the third and fourth inter- metatarsal space is continuous with the intertarsal space of the lateral cu- neiform and the cuboid. 28 Other radiographic findings may assist with diagnosis. The fleck sign, or avulsion of Lisfranc’s ligament at the base of the second metatarsal, is diagnostic of TMC injury 9 (Fig. 2, C). Analysis of the medial column line on an anteroposterior abduction stress view may reveal subtle injury 26 (Fig. 3). Flattening of the longitudinal arch may suggest injury to the TMC and can be evaluated by comparing the weight-bearing lateral view to that of the uninjured foot. 29 Computed tomography (CT) has proved to be a valuable tool in the di- agnosis of injuries to the TMC. It is more sensitive than plain radiographs in detecting minor displacement and small fractures. 30-32 Displacement of up to 2 mm may not be detectable on plain radiographs but is visible on CT. 31 Axial and coronal views of both feet should be made for comparison. Subtle widening or dorsal sublux- ation of the metatarsals are CT find- ings suggestive of TMC disruptions, and avulsion fracture of the second metatarsal base is diagnostic of in- jury 33 (Fig. 4). In high-energy fracture- dislocations, a preoperative CT may facilitate surgical planning by delin- eating the extent of osseous injury. The role of magnetic resonance im- aging (MRI) in evaluating TMC inju- ries has yet to be defined. MRI is more sensitive than plain radiographs in detecting small fractures and joint malalignment and in assessing liga- mentous structures around the TMC. 33,34 However, with regard to di- agnosis and decision-making, CT is superior to MRI. 30 Therefore, MRI is not routinely recommended in the as- sessment of these injuries. Classification The earliest classification system was published in 1909 by Quenu and Kuss 12 and subsequently modified by Hardcastle et al 13 in 1982 and Myer- son et al 9 in 1986. The most recently published classification system, pub- lished by the Orthopaedic Trauma Association, 35 is similar to the orig- inal Quenu and Kuss classification. These classification systems are all based on the congruency of the TMT joints and the direction of displace- ment of the metatarsal bases. Com- mon to all classification systems is that none appears to be helpful in terms of management or prognosis. 9 Management Nonsurgical management of TMC in- juries should be limited to those that are without fracture, nondisplaced, and stable under radiographic stress examination. As little as 2 mm of dis- placement or the presence of a frac- ture within the TMC warrants fixa- tion. Nondisplaced, stable ligamentous injuries may be treated in a non– Figure 3 Medial column line. On an anteroposterior radiograph with the forefoot stressed in abduction (dashed outline of first metatarsal), a line is drawn tangential to the medial bor- ders of the navicular and medial cuneiform (heavy dashed line). Failure of this line to in- tersect the base of the first metatarsal is strongly suggestive of TMC injury. A, Normal foot. B, First, second, and third TMT joint disruption (heavy dark line). Arrows indicate direction of forces. (Adapted with permission from Coss HS, Manos RE, Buoncristiani A, Mills WJ: Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tar- sometatarsal joint. Foot Ankle Int 1998;19:537-541.) Michael C. Thompson, MD, and Matthew A. Mormino, MD Vol 11, No 4, July/August 2003 263 weight-bearing short leg cast for a minimum of 6 weeks. Radiographic examination should be done 1 to 2 weeks after injury to ensure that align- ment and stability are maintained. Gradual weight bearing in a protec- tive brace may begin at 6 weeks. Per- mission for unrestricted activity, such as running and jumping, should be withheld for 3 to 4 months. Although displaced or unstable TMC injuries have been treated by closed reduction and casting, loss of reduction was common and outcomes were variable, with a high incidence of poor results. Currently accepted sur- gical techniques involve either closed reduction with percutaneous Kirsch- ner wire (K-wire) or screw fixation 2 or open reduction with screw and/ or K-wire fixation. 4-6 For fixation of the medial three TMT joints, screw fix- ation may be preferable to K-wires be- cause ligamentous healing may re- quire as much as 12 to 16 weeks of immobilization to occur, and K-wires can become loose, necessitating re- moval as early as 6 weeks. Regard- less of the technique used, the goal should be anatomic reduction of the affected joints because numerous stud- ies have documented that clinical out- come correlates with accuracy of reduction. 1,5-9,12,21,36,37 Ideally, surgical management of closed injuries is undertaken when soft-tissue swelling is at a minimum, either immediately or after swelling has abated. This delay may take up to 2 weeks and can be identified by the return of wrinkles to the skin. The initial incision is made dorsally be- tween the first and second web space. The extensor hallucis longus tendon, deep peroneal nerve, and dorsalis pe- dis artery are identified and retract- ed as a unit, allowing deep, sharp dis- section to expose the first and second TMT joints. Small, irreducible bone fragments are débrided from the joints. The reduction should begin medially and progress laterally. Aligning the medial aspect of the first metatarsal and the medial cuneiform reduces the first TMT joint. The en- tire medial aspect of this joint is ex- posed to ensure that plantar gapping is not present. The reduction is pro- visionally held with a K-wire, and the joint is stabilized with a countersunk 3.5- or 2.7-mm screw placed from the base of the first metatarsal into the medial cuneiform. Using fully thread- ed cortical screws placed for position- ing, rather than compression, is pref- erable. Screws crossing otherwise normal joints result in little, if any, long-term morbidity. If rotational in- stability of the first TMT joint persists after placement of the first screw, a second screw or K-wire may be placed from the medial cuneiform into the base of the first metatarsal. The second metatarsal is then re- duced to the medial border of the middle cuneiform and temporarily held with a K-wire. Definitive fixation follows with a 3.5- or 2.7-mm coun- tersunk screw directed from the base of the second metatarsal into the mid- dle cuneiform. A 3.5-mm screw is usually appropriate for most patients; a 2.7-mm screw may be used for pa- tients of small stature or when there is concern about the size of the 3.5- mm screw relative to the diameter of the second metatarsal. Medial column fixation is then completed by placing a 3.5- or 2.7-mm screw from the me- dial cuneiform into the base of the second metatarsal. If the third TMT joint is disrupted and remains unstable after fixation of the first and second TMT joints, a sec- ond dorsal incision is made between the third and fourth metatarsals to ex- pose the third TMT joint. This joint is similarly reduced and fixed with a 3.5- or 2.7-mm screw directed from the base of the third metatarsal into the lateral cuneiform. Reduction of the fourth and fifth TMT joints usu- ally occurs with reduction of the me- dial three TMT joints and is secured with percutaneous K-wire fixation (Fig. 5). Alternative fixation, although typically unnecessary, is done with screw fixation. Occasionally, an associated impact- ed (nutcracker) fracture of the cuboid may require treatment. The technique described by Sangeorzan and Swiont- kowski 38 involves restoration of cuboid length by distraction bone grafting and plating. Failure to restore length re- sults in lateral column shortening and a persistently abducted and pronated forefoot. A distractor or external fix- ator may be used intraoperatively to facilitate distraction before plating (Fig. 6). Associated fractures of the navicu- lar may be exposed and stabilized by Figure 4 A, Coronal CT scan demonstrating subtle widening (arrow) of the first and sec- ond metatarsal bases. B, Coronal CT scan showing an avulsion fracture (arrow) of the sec- ond metatarsal base. Injury to the Tarsometatarsal Joint Complex 264 Journal of the American Academy of Orthopaedic Surgeons extending the dorsal medial incision proximally. In most cases, fragments are large enough to accommodate 3.5- or 2.7-mm screws placed using a lag technique. Rarely, severely comminuted or contaminated injuries of the TMC may not be amenable to internal fixation using standard techniques. Temporary or definitive spanning external fixa- tion is an option for these difficult cas- es. Limited percutaneous fixation with K-wires or screws may augment sta- bilization but should be used with cau- tion in contaminated cases. Wound closure should be accom- plished with meticulous soft-tissue handling and closure.Ashort leg, non– weight-bearing cast is maintained for 6 weeks. Any percutaneous pins are then removed, and the patient is ad- vanced to full weight bearing in a walking boot for an additional 4 to 6 weeks. The indication for screw re- moval remains controversial. 2,5 Most authors recommend routine remov- al of the screws either on weight bear- ing or approximately 16 weeks after fixation. 2 We prefer to remove screws only if patients are symptomatic but no sooner than 16 weeks postopera- tively. Broken screws seem to occur in only a minority of patients. Further- more,affectedpatientsareoftenasymp- tomatic, although broken screws may be problematic if salvage by fusion is necessary. When a compartment syndrome is diagnosed at the initial evaluation, emer- gent fasciotomy should be done. 23 Us- ing the two dorsal incisions described, the interosseous compartments areeach released. Dissection between the meta- tarsals is done to achieve release of the medial, central, and lateral com- partments (Fig. 7). Rarely, associated hindfoot injuries such as a calcaneus fracture may be present and may re- quire release of the calcaneal compart- ment. This may be achieved through a longitudinal medial incision over the compartment.After fasciotomy, defin- itive fixation should be done. Fascial compartments and wounds should be left open, and the patient may undergo redébridement and attempted wound closure within 48 to 72 hours. Delayed primary wound closure may not be possible, and coverage with split- thickness skin graft maybenecessary. 23,24 Open TMC fracture-dislocations should be treated as surgical emergen- cies. Débridement and irrigation should be done within 6 hours of injury, if possible. In addition to tetanus pro- phylaxis, Gustilo and Anderson type I and II open injuries should receive a first-generation cephalosporin, with an aminoglycoside added for type III injuries. Severe contamination or vas- cular compromise requires adding pen- icillin G to the antibiotic regimen. Wounds are left open and covered with saline gauze or an equivalent dress- ing. Repeat débridement and irriga- tion are done every 48 hours until a clean, viable wound bed is achieved. Ideally, wound closure is achieved by delayed primary closure. In the foot, however, this is often not possible. Coverage may be achieved by split- thickness skin graft, free tissue trans- fer, or local rotation flaps, according to surgeon preference and institution capabilities. Results In 1986, Myerson et al 9 published a retrospective study of 76 TMT joint injuries treated over a 10-year peri- od. Six open injuries were included. Treatment methods comprised immo- bilization alone, closed reduction and casting, closed reduction and percu- taneous K-wire fixation, and open re- duction followed by K-wire fixation. Fifty-five injuries were followed up at a mean of 4.2 years (range, 1.6 to 11 years). Immobilization alone or closed reduction and casting result- ed in 0 of 5 and 3 of 15 (20%) good and excellent results, respectively. In contrast, good to excellent clinical re- sults were documented in 9 of 17 pa- tients (53%) who underwent closed reduction and percutaneous pinning as well as in 14 of 18 patients (78%) Figure 5 Typical fixation scheme for a TMC disruption. Figure 6 Restoration of cuboid length with bone graft and a plate. An external fixator or distractor may be used intraoperatively to fa- cilitate distraction. (Adapted with permission from HansenST Jr: Acutefractures in thefoot, in Hansen ST Jr: Functional Reconstruction of the Foot and Ankle. Philadelphia, PA: Lippin- cott Williams & Wilkins, 2000, pp 65-103.) Michael C. Thompson, MD, and Matthew A. Mormino, MD Vol 11, No 4, July/August 2003 265 treated with open reduction and K-wire fixation. Seven of the eight di- rect crush injuries had fair to poor functional outcomes (88%). Overall, the quality of reduction, which was a subjective assessment of TMT joint alignment, correlated with the clin- ical result. Good to excellent results were achieved in 22 of 26 patients (85%) with an acceptable reduction and in only 5 of 29 patients (17%) with an unacceptable reduction. The au- thors concluded that the major deter- minants of unacceptable results are the damage to the articular surface at the time of injury and the quality of the initial reduction. 9 In 1988, Arntz et al 6 published their results of 41 TMC injuries in 40 pa- tients treated with open reduction and screw fixation. Seven of the injuries were open fracture-dislocations.Atsur- gery, intra-articular fracture or peri- articular comminution was noted in 54% of injuries (22/41). Anatomic re- duction (within 2 mm) was achieved in 97% of the closed injuries (33/34) and in 88% overall (36/41). Hardware was removed from all patients at a min- imum of 12 weeks. Thirty-four patients (35 injuries) were followed up at a mean of 3.4 years after injury. Good or excellent functional results were re- ported for 93% of closed injuries (27/ 29). In contrast, four of the six patients with open fractures had a fair or poor functional result. In all patients, the presence of degenerative changes on follow-up radiographs negatively cor- related with functional outcome. Ra- diographic evidence of posttraumatic degenerative changes was absent or minimal in 26 of the 30 injuries with an anatomic reduction (87%). Con- versely, all five injuries with nonana- tomic reduction after surgery devel- oped moderate or severe posttraumatic arthritis. In general, patients who sus- tained open injuries were more likely to have periarticular comminution noted intraoperatively, more advanced posttraumatic degenerative changes at follow-up, and a worse functional outcome. The authors concluded that injury to the articular cartilage and fail- ure to achieve an anatomic reduction were the most important determinants in the development of posttraumatic arthritis. Furthermore, they stressed the importance of open anatomic re- duction followed by rigid screw fix- ation in optimizing outcome. 6 More recently, Kuo et al 5 reported on 92 TMC injuries treated over a 7-year period. Six open injuries were included in the study. All patients were treated surgically with the me- dial three joints stabilized with screws and the fourth and fifth joints, with Kirschner wires. Postoperatively, screws were removed only when painful. Forty-eight patients were ex- amined at a mean of 4.3 years after injury (range, 1.1 to 9.5 years), for a follow-up rate of 52%. The prevalence of radiographic posttraumatic arthri- tis was significantly (P = 0.004) lower in patients with an anatomic reduc- tion within 2 mm (6/38 [16%]) com- pared with those with nonanatomic reduction (6/10 [60%]). In addition, patients with anatomic reduction had a statistically significant (P = 0.05) bet- ter average functional score, as mea- sured by the American Orthopaedic Foot and Ankle Society score for the midfoot. Purely ligamentous injuries tended to have a higher prevalence of osteoarthritis, but without statis- tical significance. The authors con- cluded that the overall outcomes af- ter surgical treatment of these injuries are good and that anatomic reduction is important for long-term outcome. 5 Complications Posttraumatic arthritis remains the most common complication after TMC injury. Not all patients who develop degenerative radiographic changes are symptomatic. 9 In the series by Kuo et al, 5 12 of 48 patients (25%) had symp- tomatic arthritis at final follow-up. Of these, six underwent arthrodesis.Arntz et al 6 reported moderate to severe de- generative changes on follow-up ra- diographs in 9 of 35 patients (26%). Cushioned inserts, shoe modifications, and nonsteroidal anti-inflammatory medications are the mainstay of non- surgical treatment for posttraumatic arthritis after TMC injury. If these mo- dalities fail, arthrodesis of the affected joints is the treatment of choice. Figure 7 Release of compartment syndrome through dorsal incisions. (Adapted with per- mission from Myerson MS: Experimental decompression of the fascial compartments of the foot: The basis for fasciotomy in acute compartment syndromes. Foot Ankle 1988;8:308-314.) Injury to the Tarsometatarsal Joint Complex 266 Journal of the American Academy of Orthopaedic Surgeons Other complications occur with less frequency. Arntz et al 6 and Kuo et al 5 reported an incidence of broken screws of 2% and 25%, respectively. Superficial infection, residual dyses- thesias, late displacement, and deep vein thrombosis have been reported in <4% of cases. 5,6,9 Summary Injuries to the tarsometatarsal joint complex are often overlooked and can be misunderstood.An appreciationof the complex bony and ligamentous anatomy is necessary to make an ac- curate diagnosis from the appropri- ate radiographic studies. Open ana- tomic reduction and rigid internal fixation is the preferred method of management. 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